Hemorrhoids

Surg Clin N Am 82 (2002) 1153–1167

Hemorrhoids T. Cristina Sardinha, MD, Marvin L. Corman, MD* Department of Surgery, North Shore-Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA

The exact definition of hemorrhoids has been difficult to formulate, if for no other reason than that the pathophysiology of this condition remains elusive. The word, hemorrhoid (haima ¼ blood; rhoos ¼ flowing), derives from the Greek adjective, haimorrhoides [1]. As a disease entity, hemorrhoids have been reported to plague the human race since the earliest history of man. Data from the National Center for Health Statistics suggest that approximately 10 million people in the United States suffer from hemorrhoids [2]. The exact prevalence of hemorrhoids is difficult to estimate, however, because patients presenting with any anorectal symptoms assume that they are suffering from this condition. Therefore, the ultimate diagnosis and management truly must rest with an experienced clinician. This article provides an overview of hemorrhoid disease, with emphasis on newer therapeutic modalities.

Anatomy According to Thomson [3], the submucosa does not form a continuous ring of thickened tissue in the anal canal, but rather a discontinuous, series of vascular cushions. The three main cushions are found in the left lateral, right anterior, and right posterior positions. The submucosal layer of these cushions is rich in blood vessels and muscular fibers. These fibers (muscularis submucosae ani) arise from the internal sphincter and the conjoined longitudinal muscle, and are responsible for maintaining adherence of mucosal and submucosal tissues to the internal sphincter and blood vessels of the submucosa. These vascular cushions may protect the anal canal from injury by filling with blood during defecation. * Department of Surgery North Shore/Long Island Jewish Medical Center, 269-11 76th Avenue, Suite #FP 417, New Hyde Park, NY 11040. E-mail address: [email protected] (M.L. Corman). 0039-6109/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 0 3 9 - 6 1 0 9 ( 0 2 ) 0 0 0 8 2 - 8

1154

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

The blood supply to the vascular cushions in the anal canal is provided by the terminal branches of the superior hemorrhoidal artery, and by branches of the middle hemorrhoidal arteries. Terminal branches of the inferior hemorrhoidal arteries, which supply the lower portion of the anal canal, also participate in the network of intercommunicating vessels of the anal cushions. The venous drainage from the anal canal is established by the superior, middle, and inferior hemorrhoidal veins [4]. Pathophysiology and etiology The deterioration of supporting tissue to the vascular cushions in the anal canal produces venous distension, erosion, bleeding, and thrombosis. Several theories have been postulated regarding the cause of hemorrhoids; however, the precise etiology of hemorrhoids is still unknown. Among the many attempts to explain hemorrhoids are: venous obstruction secondary to congestion and hypertrophy of the anal cushions, prolapse or downward displacement of the anal cushions, destruction of anchoring connective tissue, and abnormal dilatation of the veins of the internal hemorrhoidal plexus. Other factors, such as heredity, age, anal sphincter tone, diet, occupation, constipation, and pregnancy, have also been implicated in the cause of hemorrhoids [4]. Classification Hemorrhoids are classified according to location and degree of prolapse. The dentate line separates internal from external hemorrhoids. Internal hemorrhoids arise proximal to the dentate line from the superior hemorrhoidal plexus and are covered by mucosa. Conversely, external hemorrhoids are located distal to the dentate line, arise from the inferior hemorrhoidal plexus, and are covered by squamous epithelium. Mixed hemorrhoids (internal-external) are present above and below the dentate line and arise from the superior and inferior hemorrhoidal plexus and their anastomotic communications. Hemorrhoids are also graded according to the degree of prolapse as follows [4–6]: First degree: Cushions located above the pectinate line that do not descend upon straining. They are usually associated with bleeding at the time of defecation. Second degree: Cushions that protrude below the pectinate line during straining but return spontaneously to within the anal canal once straining stops. Third degree: Cushions that protrude to the exterior of the anal canal during straining or defecation and require manual reduction back into the anal canal.

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

1155

Fourth degree: Cushions that are irreducible and remain constantly prolapsed independent of straining or defecation. Diagnosis A detailed history is one of the cornerstones for establishing the diagnosis of hemorrhoids. The color and character of anorectal bleeding and the relief obtained from reduction of prolapsed hemorrhoids into the anal canal lead the examiner to the diagnosis. One should always keep in mind other anorectal pathologic conditions that may present with similar symptoms. These include rectal prolapse, polyps, carcinoma, hypertrophied anal papilla, skin tags, fissure, fistula, and perianal infections. Patients with hemorrhoids often complain of bleeding during or after defecation, frequently exacerbated by straining. Blood can be evident on the toilet paper or within the toilet bowl, or both. Occasionally, blood loss can cause severe anemia or even require blood transfusion. Bleeding is more commonly associated with internal hemorrhoids. Kluiber and Wolff [7] found that the incidence of anemia attributed to hemorrhoids was 0.5 per 100.000 people per year in Olmsted County, MN. Uncomplicated hemorrhoidal disease is usually painless. Thrombosis, ulceration, or gangrene of the pile may cause significant pain and discomfort. An adequate physical examination should include a careful inspection, palpation, digital examination, anoscopy, and proctosigmoidoscoy. The use of anorectal physiologic studies as a tool for the diagnosis of hemorrhoids has yet to be determined. Preoperative manometric studies may be of value in patients who are at risk for the development of postoperative incontinence, however. A thorough inspection and palpation is required to differentiate hemorrhoids from perianal Crohn’s disease. Inspection is also important in the diagnosis of a concomitant anal fissure. Inspection and palpation should readily differentiate a thrombosed hemorrhoid, a tumor, or an abscess. Anoscopy and proctoscopy will demonstrate the internal vascular cushions and may also show active bleeding. Evidence of hemorrhoid bleeding does not exclude other causes of rectal bleeding, however. Therefore, further investigation, such as colonoscopy or barium enema, may be warranted in patients whose symptoms suggest proximal colon pathology. Complete colonic evaluation should be performed at some point in those who are at a risk based on family history, or are at an age for colonic screening evaluation.

Treatment Numerous therapeutic modalities have been used to manage hemorrhoids. A good understanding of the pathophysiology of hemorrhoids helps one to select the most appropriate technique for treatment. Traditionally,

1156

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

the management of hemorrhoids has been based on the degree of prolapse of the vascular cushions and the severity and type of symptoms. Most of the available options for treatment of hemorrhoids are performed as outpatient procedures. Guidelines have been established by the Standards Task Force of the American Society of Colon and Rectal Surgeons to describe practice parameters for the management of ambulatory anorectal surgery, including hemorrhoidal disease [8]. Nonoperative management and minor surgical procedures Conservative medical management of hemorrhoids can be accomplished in the majority of patients. These nonsurgical options vary from advice with respect to defecation habits, local hygiene, and dietary manipulations, to minor procedures such as injection or rubber band ligation. Neglecting the first urge to defecate, spending a prolonged time at the toilet, and straining are common defecation errors. Hemorrhoidal disease, particularly third and fourth degree, are often associated with mucous staining and itching. These symptoms often require advice about anal hygiene to prevent perianal dermatitis and to ameliorate symptoms. A high-fiber diet is associated with an improvement in bowel habits and reduction in constipation. Furthermore, the addition of bulk-forming agents to a normal diet can minimize the amount of trauma to the anal canal epithelium caused by hardened stools, therefore reducing the likelihood of ulceration and bleeding [9]. The use of sitz baths and warm soaks to ameliorate symptomatic hemorrhoids, especially thrombosis, is also commonly recommended. Ice packs to decrease swelling shortly after it becomes evident have also been recommended. A large variety of topical agents, such as creams, lotions, suppositories, and local anesthetics, have been employed with the purpose of improving hemorrhoidal symptoms. These commercial preparations, including Anusol, Tucks, Balneol, and Preparation H, among others, are common self-medications that have become ubiquitous in the Western population [4,5]. The efficacy of such products has yet to be proved. However, anecdotal evidence suggests some symptomatic relief of hemorrhoidal disease can be achieved with the use of topical medications. Topical nitric oxide has been reported as an alternative for managing strangulated internal hemorrhoid by decreasing internal anal sphincter tone [10]. Even though topical agents may improve symptoms, it is unlikely that they will eliminate and ultimately cure the hemorrhoids. Manual dilatation of the anal canal, described by Lord in 1968, was based on the hypothesis that hemorrhoids were a consequence of narrowing of the anal canal due to a ‘‘pecten band’’ [4–6]. This procedure has fallen into disrepute because of concerns about anal incontinence. Konsten and Beaten reported a 17-year follow-up of patients who underwent Lord’s procedure for the treatment of second and third degree hemorrhoids [11]. They documented that 52% of these patients developed anal incontinence. Based

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

1157

on these findings, the authors concluded that the use of anal dilatation for the treatment of hemorrhoids should be abandoned. Injection of sclerosing agents causes fibrosis of the vascular cushions, and therefore obliterates the hemorrhoids. This approach is usually applied to the treatment of first and second degree hemorrhoids. However, sclerotherapy is contraindicated in the management of external hemorrhoids, thrombosed, or ulcerated internal hemorrhoids, as well as in the presence of inflammatory or gangrenous piles. John Morgan first attempted sclerotherapy to obliterate hemorrhoids as early as 1869 by using iron persulphate [4]. From 1871, this technique was advertised in the United States as a ‘‘painless cure for piles without surgery.’’ Unfortunately, inappropriate technique of injection and toxic chemical agents were linked to serious complications, including death [4]. Improved techniques and appropriate dosing of sclerosing agents, however, afford good results in properly selected patients. Chemical agents used for sclerotherapy include phenol (5%) in vegetable oil, quinine and urea hydrochloride, sodium morrhuate, and sodium tetradecyl sulfate. Despite its relative usefulness, few reports have been published in English language journals in recent years [12,13]. This technique should be limited to symptomatic first and second degree hemorrhoids in those patients for whom rubber band ligation cannot be tolerated (see later). Injection sclerotherapy may also be advisable for patients with coagulation disorders. The principle of cryotherapy is based on cellular destruction through rapid freezing followed by rapid thawing. This freezing temperature achieved with nitrous oxide at
60°C to
80°C or liquid nitrogen at
196°C can eliminate hemorrhoids by necrosing the vascular cushions [6]. This procedure is associated with profuse foul-smelling discharge and irritation. In addition to pain and slow healing, the inappropriate use of cryotherapy can cause necrosis of the internal anal sphincter, resulting in anal stenosis and incontinence. Therefore, because this procedure does not offer any advantage compared with other forms of treating hemorrhoids and is associated with high morbidity, it is now generally believed that cryosurgery should be eliminated from the therapeutic armamentarium in the management of hemorrhoid disease. The use of infrared coagulation was first described by Neiger in 1979 [14]. Infrared light penetrates the tissue and is converted to heat, which causes tissue destruction. The use of a 1.5s pulse generates a tissue temperature of 100°C, which results in a 3 mm depth of coagulated protein [15]. As with injection, the primary benefit is in individuals with smaller hemorrhoids and in those whose symptoms (especially bleeding) are not amenable to rubber band ligation. Rubber band ligation has become one of the most frequently applied methods for the treatment internal hemorrhoids. The instrument for rubber band ligation was originally described by Blaisdell in 1954 and later modified by Barron [4]. Since then, the results obtained by this technique have

1158

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

been so gratifying that this approach has replaced surgical hemorrhoidectomy for approximately 80% of patients. Rubber band ligation is a simple, inexpensive, office-based procedure that can be applied to most individuals with bleeding and or prolapsed hemorrhoids. It is ideal for the treatment of second and third degree hemorrhoids. The rubber rings should be placed on an insensitive area at or just above the dentate line. The use of an anesthetic is unnecessary. Following a cleansing enema, a proctosigmoidoscopy and anoscopy are performed. Multiple ligations at three to four week intervals may be required, depending on the number of piles that must be banded and the individual’s response to therapy. Controversies exist about the number of piles that can be banded in any one session. Generally, we believe that the placement of two or more rubber rings in the first treatment session should be avoided, because multiple bandings may lead to excessive discomfort and the potential for greater complication. Although Law and Chou [16] reported triple rubber band ligation in a single session as safe and cost-effective, postligation pain occurred in up to 37% of patients. A high-fiber diet with bulking agents and stool softeners is usually recommended following banding. Rubber band ligation is associated with a low complication rate (\2%). Complications include a vaso-vagal response to anoscopy and the placement of the bands, anal pain, and, rarely, pelvic sepsis. Secondary thrombosis of the external component may also be seen and occurs in from 2% to 11% of patients following banding [17]. The management of this condition is similar to that of spontaneous thrombosis of external hemorrhoids. Delayed bleeding after banding usually occurs 7 to 10 days postprocedure as the banded bundle sloughs. Hemorrhage is rare (0.5%), as has been reported by Rothberg and others [18,19]. Rubber band ligation offers excellent results in the treatment of internal hemorrhoids. Patient satisfaction has been well documented—80% to 90%. Sixty to 70% are cured with a single treatment session. If symptoms persist after two or more banding sessions, however, surgical hemorrhoidectomy should be considered [17,20]. A meta-analysis of treatment modalities for hemorrhoidal disease demonstrated that rubber band ligation was the procedure of choice for the management of first through third degree hemorrhoids [21]. Operative treatment Lateral internal sphincterotomy alone for the treatment of hemorrhoids is based on the principle that patients selected for it have high resting anal canal pressures [22]. A study conducted by Leong and colleagues, however, reported no advantage in combining internal sphincterotomy with hemorrhoidectomy [23]. Although lateral internal sphincterotomy may be recommended in selected patients with concomitant hemorrhoids and anal fissure, this technique should be abandoned as the sole treatment for hemorrhoidal disease.

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

1159

Surgical hemorrhoidectomy should be considered in the presence of an external component, ulceration, gangrene, extensive thrombosis, hypertrophied papillae, associated fissure, or failure of rubber band ligation to alleviate symptoms. In the United States, most surgical hemorrhoidectomies are performed as an outpatient procedure. The choices of anesthesia and patient positioning are individualized and are generally based on patient condition and surgeon preference. Most hemorrhoidectomies are performed by using a local anesthetic combined with mild sedation. We prefer to place the patient in the prone jackknife position with the buttocks taped apart. This position offers good exposure of the anus and provides greater comfort for the assistant. Many alternative techniques have been described to surgically extirpate hemorrhoids, but today the primary variable is whether the surgical wound is closed or left open. The closed technique (the so-called Ferguson hemorrhoidectomy) is the method adopted by most surgeons. After infiltrating the anus with a local anesthetic (eg, 0.5% bupivacaine in 1:200,000 epinephrine solution), a Hill-Ferguson retractor is placed into the anal canal to reveal the extent of hemorrhoids. The next step is the placement of a clamp, incorporating any skin tag as well as the vascular cushion to be excised. Excision is accomplished with a scalpel, scissors, or electrocautery. The laser has also been used as a cutting tool for this purpose, but has no advantage and is expensive. The incision should be carried beyond the anal verge, removing the external hemorrhoidal plexus, and proximally into the anal canal. The internal sphincter is carefully dropped away from the plane of dissection. After complete dissection and mobilization of the hemorrhoid pedicle, a suture ligature is placed using absorbable material, and the hemorrhoid is excised. Hemostasis is achieved with electrocautery or with the suture. The wound is completely closed with a continuous suture, using the same stitch employed to ligate the pedicle. A small dressing is applied following cleansing of the wound. Bulky pressure dressings or packing are not indicated because they produce more pain. Excision of three or more pile sites has been the traditionally favored surgical approach. However, the Ferguson Clinic group has suggested a limited hemorrhoidectomy, with excision of only one or two pedicles, to treat symptomatic hemorrhoids [24]. With this approach, fewer than 2% of patients required further therapy. Moreover, the incidence of complications was significantly lower with this limited hemorrhoidectomy. A sutureless, closed hemorrhoidectomy was recently reported by Sayfan and coworkers to be a safe and rapid procedure for the treatment of third and fourth degree hemorrhoids, as well as that of associated skin tags [25]. This method was also associated with fewer complications and a shorter convalescence when compared with the open procedure. Prospective randomized trials and long-term follow-up are imperative if one is to properly evaluate any new therapy. Open hemorrhoidectomy is an option when the wound cannot be completely closed, even with a narrow retractor in place, or in the presence of

1160

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

gangrene or circumferential hemorrhoids. The procedure is identical to the technique previously described for the Ferguson operation, except that the procedure ends after ligation of the pedicle. The mucosa and perianal skin are left open and hemostasis is established with electrocautery. Alternatively, a semiclosed procedure can be performed, closing the anal canal mucosa and leaving the perianal skin open. Both open and closed hemorrhoidectomies are acceptable options in the treatment of hemorrhoids. The closed method is generally felt to be associated with earlier wound healing. Postoperative pain is probably similar to that with the open technique [26]. Complications following surgical hemorrhoidectomy are frequently related to surgical technique and to issues of postoperative management. Fear of pain is the most important reason why patients avoid hemorrhoidectomy. Many alternatives have been directed to minimizing postoperative pain, most recently stapled hemorrhoidopexy (see later). Currently, posthemorrhoidectomy pain is managed with analgesics and nonsteroidal antiinflammatory agents, stool softeners, and fiber. Urinary retention is the most frequently seen complication. The incidence varies from 10% to 32% [17]. Bleday and colleagues reported a 20% incidence of postoperative urinary complications [27]. A number of contributing factors have been implicated as leading to urinary retention. These include the use of spinal anesthesia, fluid overload, rectal packing, rectal pain and spasm, and bulky dressings [4]. Urinary tract infection is usually a result of catheterization for urinary retention. Bleeding is frequently related to inadequate hemostasis or mass ligation of the hemorrhoid pedicle instead of suture ligature. Returning the patient to the operating room is usually required. The incidence of postoperative bleeding varies from 2% to 4%. Only 0.8% to 1.3% require reoperation, however [17]. Delayed hemorrhage (ie, 7 to 14 days postoperatively) is probably a result of sepsis within the pedicle. This occurs following approximately 2% of hemorrhoidectomies. Delayed bleeding is usually not a preventable complication. The management of bleeding includes injection with epinephrine solution, direct pressure with or without topical epinephrine, and suture ligation. Other less frequent early complications include wound infection (\I%), fecal impaction, and external vein thrombosis. Late complications can be found in up to 6% of hemorrhoidectomies. Anal fissure is the most common, accounting for 1% to 2.6%, followed by anal stenosis (1%) [17]. Other concerns include incontinence (0.4%), anal fistula (0.5%), recurrent hemorrhoids (\l%), skin tags, ectropion, and mucosal prolapse [4,17]. Most recently, a modified circular stapling approach has been advocated for the surgical management of hemorrhoids. The so-called Procedure for Prolapsed Hemorrhoids (PPH) was described initially by Longo in 1998 [28]. The reported success and growing acceptance of this technique by European and Asian surgeons has stimulated the desire for a prospective

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

1161

randomized trial in the United States. The rationale for stapled hemorrhoidopexy (not ‘‘hemorrhoidectomy’’) is based on the concept that interruption of the superior and middle hemorrhoidal vessels, and the upward lifting of the prolapsed anorectal mucosa and repositioning of the vascular cushions back into the anal canal cause the hemorrhoidal tissue to atrophy. This technique addresses the theoretical concept that hemorrhoids represent downward sliding of the anal canal lining, which results in elongation and kinking of the upper and middle hemorrhoidal vessels [3]. Stapled hemorrhoidopexy has been mainly advocated for third and fourth degree internal hemorrhoids. Conversely, external hemorrhoids are not appropriately treated by this means, but the tags and external component can be concomitantly excised if indicated. Residual external hemorrhoids may actually be partially or completely drawn into the anal canal with the PPH, or may atrophy and become asymptomatic [29]. Even though stapled hemorrhoidopexy has been advocated for the treatment of second degree hemorrhoids [30], in the absence of a prospective, randomized trial we believe that these hemorrhoids are better treated by rubber band ligation. Technique of Stapled Hemorrhoidopexy A modified 33 mm circular stapler is used to perform the stapled hemorrhoidopexy [31]. This operation is facilitated by the use of the PPH procedural set (Ethicon Endo-Surgery, Inc., Cincinnati, OH), consisting of a circular stapler (HCS33), a suture threader (ST100), a circular anal dilator (CAD33), and a purse-string suture anoscope (PSA33) (Fig. 1). The technique for PPH involves the placement of a purse string suture, using nonabsorbable monofilament material, approximately 2 cm to 4 cm cephalad to the dentate line (Fig. 2). The suture is placed into the mucosa and submucosa of the lower rectum, avoiding the muscular layer and vagina. Care must be taken to place the purse string sufficiently high so that when fired it does not incorporate the anal mucosa and underlying internal anal sphincter. If this were to occur, severe pain might ensue, in addition to the risk of stricture and mucosal ectroprion [32,33]. These complications should be avoidable if the purse string is placed at least 2 cm above the dentate line [28,34]. The single greatest advantage of stapled hemorrhoidopexy is the reduction in postoperative pain. This has been demonstrated in several prospective trials that compared this approach with that of Milligan-Morgan hemorrhoidectomy. The pain after PPH has been described as vague, dull, and analogous to tenesmus, but differing from the severe, sharp, anal pain associated with conventional hemorrhoid surgery [33]. Mehigan and coworkers prospectively randomized 40 patients to undergo PPH hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy [35]. The average postoperative pain score from postoperative day zero to day ten was significantly lower in the PPH group compared with the Milligan-Morgan hemorrhoidectomy group. By using two 10 cm linear analogue scales, the authors

1162

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

Fig. 1. PPH set of instruments.

also evaluated the degree of pain related to what the patient expected. This was also lower in the PPH group. Similar results were reported by Rowsell and colleagues in 22 randomized patients [36]. Larger controlled trials also demonstrated that PPH hemorrhoidopexy diminished postoperative pain when compared with conventional hemorrhoidectomy [29,30,37,38]. Moreover, stapled hemorrhoidopexy was also associated with a shorter hospital stay and a faster return to full activity [39]. The reported complication rates of hemorrhoidopexy have been similar to those of conventional hemorrhoidectomy (Table 1). One case report of severe pelvic sepsis was noted [39], however, as was the development of a recto-vaginal fistula [40]. The latter complication should be avoided by performing a digital vaginal examination before firing the stapler, to confirm that the vaginal mucosa has not been incorporated into the stapler. Shortterm results of stapled hemorrhoidopexy are very encouraging, especially for third and fourth degree hemorrhoids. Long-term follow-up is required before one feels comfortable, especially with respect to recurrence. Cer-

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

1163

Fig. 2. Purse string placement.

tainly, one downside is the cost of the equipment. It is expensive when compared with the paucity of special requirements associated with conventional surgical hemorrhoidectomy. Moreover, the vast majority of hemorrhoidectomies in the United States are performed on an outpatient basis. Comparing the European and Asian inpatient approach for conventional surgery is, therefore, inappropriate. This new technique of stapled hemorrhoidopexy is an exciting development in the search for a relatively painless procedure to treat hemorrhoidal disease, and it has been greeted with a mixture of skepticism, interest, and enthusiasm. Multicenter, prospective, randomized trials with long-term follow-up are awaited. Special considerations Thrombosed external hemorrhoids usually present as a painful, tender mass in the anus, frequently following an episode of constipation or diarrhea. This manifestation is also associated with excessive straining or spending a prolonged time on the toilet. If the patient presents with severe pain, ulceration, rupture, or onset of the condition within 48 hours, excision is the preferred treatment. Conversely, if the discomfort is mild or if the problem is present for greater than two or three days, and the discomfort seems to be dissipating, sitz baths, stool softeners, and analgesics may be the best

57 40 100 140 50 20

Ho [29] Boccasanta [37] Shalaby [30] Arnaud [32] Ganio [38] Mehigan [35]

NA, non applicable.

Patients

Author

4.8 20 12 18 16 11

Mean follow-up (months)

2.1 2.0 1.1 1.5 1.0 1.0

Mean hospital stay (days)

Table 1 Postoperative complications after stapled hemorrhoidopexy

8.8 12.5 1.0 5.0 6.0 5.0

Bleeding % 1.8 10.0 7.0 1.4 6.0 5.0

Urinary retention % NA 2.5 0.0 NA 0.0 5.0

Incontience % NA 7.5 2.0 3.5 NA 0.0

Stenosis %

1.8 15.0 3.0 1.4 NA NA

Thrombosis%

3.5 5.0 4.0 1.4 NA 20

Skin tags %

1164 T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

1165

therapeutic options. The use of topical nifedipine is suggested by Perroti and colleagues [41]. Thrombosed internal hemorrhoids are often attributed to prolapse of the internal component with inadequate reduction, resulting in venous stasis and thrombosis of the vascular cushion. In addition, all the previously mentioned factors that may cause thrombosis of external hemorrhoids are also responsible for thrombosis of internal piles. The management of acute thrombosed internal hemorrhoid is usually nonoperative, because pain is not a frequent complaint. Sitz baths, stool softener, and mild analgesics are recommended. Brief and coworkers suggest topical isosorbide dinitrate ointment as an effective alternative to treat acute strangulated prolapsed internal hemorrhoids [10]. They follow this with rubber band ligation after resolution of the symptoms. Surgical treatment is advisable in the presence of concurrent extensive hemorrhoids, skin tags, and anal fissure. Even though conservative treatment of strangulated hemorrhoids is employed in most instances, the continued discomfort, prolonged disability, and financial burden may warrant urgent operation for all such individuals. The presence of gangrene, prolapsed, and edematous hemorrhoids usually causes severe pain, swelling, bleeding, foul-smelling discharge, and difficulty evacuating. The treatment of this condition consists of careful reduction of the hemorrhoids into the anal canal under local anesthesia with sedation, followed by pressure dressing and taping the buttocks together. Ideally, the patient should be admitted to the hospital and a hemorrhoidectomy performed on the following day. This approach allows for the swelling to decrease and for avoiding excessive removal of anal canal mucosa, thereby minimizing the risk of anal stricture. Hemorrhoidal disease in patients with human immunodeficiency virus (HIV) can be safely managed as in noninfected patients in the early stage of disease [42]. Patients with acquired immunodeficiency syndrome (AIDS), however, are at high risk for complications (ie, infection, nonhealing wounds), and probably should not undergo surgery except under well-controlled circumstances. Scaglia and associates treated 22 AIDS patients with bleeding second to fourth degree hemorrhoids using sclerotherapy, without reported complications [43]. Nineteen patients improved after the first injection and 3 required subsequent sessions. Hemorrhoids are a very common complaint in women at all stages of pregnancy. Surgical hemorrhoidectomy should be relegated to patients suffering from complications only. Symptoms usually resolve after delivery; so conservative management is generally preferred [17]. Hemorrhoidal disease in patients with inflammatory bowel disease often leads to diagnostic and therapeutic dilemmas. Hemorrhoidal symptoms are usually exacerbated by bowel frequency. If indicated, hemorrhoidectomy can be relatively safely performed in patients if the ulcerative colitis is in remission, but should be avoided in patients with Crohn’s disease [44]. Definitive or extensive surgical treatment of any anorectal condition in

1166

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

patients with inflammatory bowel disease may result in delayed healing or nonhealing of the wound, causing greater disability to the patient than before the operation.

References [1] Hulme-Moir M, Bartolo DC. Disorders of the anorectum. Gastroenterol Clin North Am 2001;30(1):183–97. [2] Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology 1990;98:380. [3] Thomson WBF. The nature of haemorrhoids. Br J Surg 1975;62:542. [4] Corman ML. Hemorrhoids. In: Corman ML, editor. Colon and rectal surgery. 4th edition. Philadelphia: Lippincott-Raven; 1998. p. 147–205. [5] Keighley MRB, Williams NS. Haemorrhoidal disease. In: Keighley MRB, Williams NS, editors. Surgery of the anus, rectum, and colon. 2nd edition. London: W.B. Saunders Co.; 1999. p. 351–427. [6] Nivatvongs S. Hemorrhoids. In: Gordon PH, Nivatvongs S, editors. Principles and practice of surgery for the colon, rectum, and anus. 2nd edition. St. Louis: Quality Medical Publishing Inc.; 1999. p. 193–215. [7] Kluiber RM, Wolff BG. Evaluation of anemia caused by hemorrhoidal bleeding. Dis Colon Rectum 1994;37:1006. [8] Standards Task Force. American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of hemorrhoids. Dis Colon Rectum 1993;36:1118. [9] Moesgaard F, Nielsen ML, Hansen JB, et al. High-fiber diet reduces bleeding and pain in patients with hemorrhoids. Dis Colon Rectum 1982;25:454. [10] Brief JW, Zimmerman DD, Schouten WR. Treatment of acute strangulated internal hemorrhoid by topical application of isosorbide dinitrate ointment. Int J Colorectal Dis 2000;15(4):253–4. [11] Konsten J, Beaten CGMI. Hemorrhoidectomy vs. Lord’s method: 17-year. follow-up of a prospective, randomized trial. Dis Colon Rectum 2000;43:503–6. [12] Khoury GA, Lake SP, Lewis MCA, et al. A randomized trial to compare single with multiple phenol injection treatment for haemorrhoids. Br J Surg 1985;72:741–2. [13] Senapati A, Nicholls RJ. A randomized trial to compare the results of injection sclerotherapy with a bulk laxative alone in the treatment of bleeding haemorrhoids. Int J Colorectal Dis 1988;3:124–6. [14] Neiger A. Hemorrhoids in everyday practice. Proctology 1979;2:22. [15] Reis Neto JA, Quilici FA, Cordeiro F, et al. Ambulatory treatment of hemorrhoids: a prospective random trial. Coloproctology 1992;6:342–7. [16] Law W-I, Chu K-W. Triple rubber band ligation for hemorrhoids: prospective, randomized trial of use of local anesthetic injection. Dis Colon Rectum 1999;42:363–6. [17] Beck DE. Hemorrhoidal disease. In: Beck DE, Wexner SD, editors. Fundamentals of anorectal surgery. 2nd editon. London: W.B. Saunders Co.; 1998. p. 237–53. [18] Corman ML, Veidenheimer MC. The new hemorrhoidectomy. Sur Clin North Am 1973; 53:417–22. [19] Rotheberg R, Rubin RJ, Eisenstat T, et al. Rubber band ligation hemorrhoidectomy: longterm results. Am Surg 1983;49:167. [20] Wrobleski DE, Corman ML, Veideheiner MC, et al. Long-term evaluation of rubber ling ligation in hemorrhoidal disease. Dis Colon Rectum 1980;23:478–82. [21] MacRae HM, McLoad RS. Comparison of hemorrhoidal treatment modalities: a metaanalysis. Dis Colon Rectum 1995;38:687–94. [22] Schouten WR, van Vroonhoven TJ. Lateral internal sphincterotomy in the treatment of hemorrhoids: a clinical and manometric study. Dis Colon Rectum 1986;29:869–72.

T.C. Sardinha, M.L. Corman / Surg Clin N Am 82 (2002) 1153–1167

1167

[23] Leong AFP, Hussain MJ, Seow-Chen F, et al. Performing internal sphincterotmy with other anorectal procedures. Dis Colon Rectum 1994;37:1130–2. [24] Hayssen TK, Luchtefeld MA, Senagore AJ. Limited hemorrhoidectomy: results and longterm follow up. Dis Colon Rectum 1999;42:909–15. [25] Sayfon J, Becker A, Koltun L. Sutureless closed hemorrhoidectomy: a new technique. Ann Surg 2001;234(l):21–4. [26] Arbman G, Krook H, Haapaniemi S. Closed vs. open hemorroidectomy - is there any difference? Dis Colon Rectum 2000;43:311–34. [27] Bleday R, Pena JP, Rothenberger DA, et al. Symptomatic hemorrhoids: current incidence and complications of operative therapy. Dis Colon Rectum 1992;35:477. [28] Longo A. Treatment of hemorrhoidal disease by reduction of mucosa and hemorrhoidal prolapse with circular suturing device: a new procedure. In: Mundozzi, editor. 6th World Congress of Endoscopic Surgery. Rome, June 3–6, 1998. p. 777–84. [29] Ho YH, Cheong WK, Tsang C, et al. Stapled hemorrhoidectomy - cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum 2000; 43:1666–75. [30] Shalaby R, Desoky A. Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy. Br J Surg 2001;88:1049–53. [31] Wexner SID. The quest for painless surgical treatment of hemorrhoids continues. J Am Coll Surg 2001;193(2):174–8. [32] Arnaud J-P, Pessaux P, Huten N, et al. Treatment of hemorrhoids with circular stapler, a new alternative to conventional methods: a prospective study of 140 patients. J Am Coll Surg 2001;193:161–5. [33] Seow-Choen F. Stapled hemorrhoidectomy: pain or gain. Br J Surg 2001;88:1–3. [34] Milito G, Cortese F, Casciani CU. Surgical treatment of mucosal prolapse and haemorrhoids by stapler. In: Proceedings of the 6th World Congress of Endoscopic Surgery. Rome, June 3–6, 1998. [35] Mehigan BJ, Monson JRT, Hartley JE. Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomized controlled trial. Lancet 2000;355:782–5. [36] Rowsell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: randomized controlled trial. Lancet 2000;355:779–81. [37] Boccasanta P, Capretti PG, Venturi M, et al. Randomised controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse. Am J Surg 2001;182(l):64–8. [38] Ganio E, Altornare DF, Gabrielli F, et al. Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy. Br J Surg 2001;88:669–74. [39] Molloy RG, Kingsmore D. Life threatening pelvic sepsis after stapled hemorrhoidectomy. Lancet 2000;355:810. [40] Pescatori M. Stapled rectal prolapsectomy. Dis Colon Rectum 2000;43:876–7. [41] Perroti P, Antropoli C, Molino D, et al. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum 2001;44:405–409. [42] Wexner SD. AIDS: what the colorectal. surgeon needs to know. Prespect Colorect Surg 1990;2:19–54. [43] Scaglia M, Delaini GG, Destafano 1, et al. Injection treatment of hemorrhoids in patients with acquired immunodeficiency syndrome. Dis Colon Rectum 2001;44:401–4. [44] Mazier WB. Hemorrhoids. In: Mazier WB, Levin DH, Luchtefeld MA, et al, editors. Surgery of the colon, rectum and anus. Philadelphia: W.B. Saunders Co.; 1995. p. 229–54.